Wednesday, May 13, 2020

It is well established that early
identification and intervention are critical determinants in the course and
outcome of autism spectrum disorder (ASD). Although there are no
“absolute” clinical indicators of autism, some of the early “red flags”
include: • Does not smile by the age of six months • Does not respond to his or
her name • Does not cry • Does not babble or use gestures by 12 months and •
Does not point to objects by 12 months. Children with autism typically
experience delays in speech and communication skills. Not only will they often
develop spoken language later, but they are less likely to develop non-verbal
communication skills such as “joint attention,” pointing, or gesturing.

Social Communication Skills

Young children with autism
spectrum disorder (ASD) typically exhibit core deficits in social communication
skills, particularly in the areas of joint attention, shared affect,
eye-contact, conventional and symbolic gestures, and related skills in
functional and symbolic play. Children seek to share attention with others
spontaneously during the first year of life. “Joint attention” is an
early-developing social-communicative skill in which two people (usually a
young child and an adult) use gestures and gaze to share attention with respect
to interesting objects or events. Before infants have developed social
cognition and language, they communicate and learn new information by following
the gaze of others and by using their own eye contact and gestures to show or
direct the attention of the people around them. These developments in the first
two years of life are potentially important early indicators of ASD which can
facilitate earlier diagnosis. Researchers have identified five core deficits
(‘red flags’) evident in the early years, namely gaze shifting, gaze point following,
rate of communicating, joint attention and gestures; these were the strongest
predictors of symptoms of autism at three years of age.

Research

Researchers in Melbourne
Australia, working on a long-term study of children from eight months to seven
years of age found that those with autism used fewer gestures to communicate
than other kids. Parents of 1,911 children participating in the ‘Early Language
in Victoria Study’ in Melbourne, Australia, completed questionnaires about
their child’s development from infancy through to school age. At four years of
age, a group of children identified with an autism spectrum disorder (ASD) were
compared to other children from within the study; those with a developmental
delay, language impairment, or typical development. Comparisons were made
between the children’s early social communication skills (including eye-gaze,
non-verbal communication, gesture, and speech skills) at 8 months, 1 year, and
2 years of age. By one year of age, children with ASD used fewer early social
communication skills than children with typical development. The only social
communication skill that was found to be significantly different between
children with ASD and all other children, however, was the use of gesture.
Children with ASD used fewer gestures for communication than all other children
at both 1 and 2 years of age.

Implications

Speech pathologist Carly
Veness, who led the research, said there was a pattern of low gesture use among
autistic children between the ages of eight months and two years. "We
found that there was a decreased use of gestures like pointing, showing and
giving,” she commented. The researchers noted that gestural deficits almost
doubled the risk for ASD, pointing to the importance of targeting gesture
deficits in infant early intervention approaches. They conclude that their
results “… highlight the possibility of detecting risk signs for ASD as young
as 12 months of age in a community sample, thus allowing for earlier
recognition of the disorder.”

Tuesday, May 5, 2020

Challenging behavior is any behavior that interferes
with a child’s learning, engagement, and social interactions with her peers or
adults. Aggression is often observed as one form of challenging behavior in
autism. Although aggression is not itself a symptom of autism and not all autistic
individuals are aggressive, research suggests that rates of challenging behavior
may be higher in individuals with autism compared to typically developing peers
and those with other developmental disabilities. Children with autism don’t necessarily express anger, fear,
anxiety or frustration in the same way as other children. However, irritability
is a symptom of autism that can complicate adjustment at home and other
settings, and can manifest itself in aggression, tantrums, and self-injurious
behavior.

Behavior as Communication

Children
engage in problem behavior to communicate. The principles of behavior teach us that it does
not occur in a vacuum – that is, behavior does not occur without regard to the
context in which it is observed. When working with autistic children we should consider problem behavior as a communication
attempt, and should determine what skill the child needs to learn in order to
reduce the need for the problem behavior or what environmental modification
makes the behavior unnecessary.The first step to developing an
effective intervention strategy is to identify the function of
the behavior. By function, we mean what the child is trying to access by
engaging in the challenging behavior. In other words: you first must figure out
what it is the child is trying to communicate. For example, a student might exhibit challenging behaviors
with the goal of escape or the goal of seeking attention. When the curriculum
is difficult or demanding, they may attempt to avoid or escape work through
challenging behavior (e.g., refusal, passive aggression, disruption, etc.).
Similarly, they may use challenging behavior to get focused attention from
adults and peers, or to gain access to a preferred object or participate in an
enjoyable activity. Problematic behavior may also occur because of sensory
aversions. Because autistic students also have significant social and pragmatic
skills deficits, they may experience difficulty effectively communicating their
needs or influencing the environment. Thus, challenging classroom behavior may
serve a purpose for communicating or a communicative function.

Common Triggers

Research suggests that common triggers include disturbing breaks in routine, lack of sleep, jarring “sensory stimuli” (noises, lights, or smells) or even undiagnosed mental health problems. Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention. Clearly, it’s important to look beyond the behavior itself to identify the underlying cause or trigger.Children with significant aggressive behavior also tended to have mood and anxiety symptoms, and difficulty sleeping and paying attention.The studies also indicate that symptoms of aggression often overlap in patients with extreme anxiety and attention deficit issues.It has been reported that executive function deficits (e.g. issues with inhibition, working memory, planning and flexibility) are associated with anxiety and aggression in autism and may serve as a pathway to comorbid psychopathology (sensory stimuli, a change in routine, transition between activities, or physical reasons like feeling unwell, tired or hungry. Not being able to communicate these difficulties can lead to anxiety, anger and frustration, and then to an outburst of challenging behavior. Comorbidity

Children with autism experience a number of related difficulties, including sleep problems, gastrointestinal (GI) problems, sensory issues, and self-injury. Many of these problems have been associated with aggression among typically developing children, and emerging evidence suggests a similar relationship in children with autism. For example, sleep problems occur in a large percentage of autistic children, with prevalence rates ranging from 50% to 80%. Sleep problems have been found to be highly associated with aggression in typically developing children. Likewise, research suggests that children with autism and sleep problems are more likely to demonstrate aggression than those without sleep problems.

Sensory problems, including sensory over-responsivity, sensory under-responsivity, and sensory seeking are also common problems in autistic children. In typical children, sensory problems have been associated with aggressive and externalizing behavior problems. Similarly, recent studies have been found correlations between sensory problems and broadly defined externalizing problem behaviors in autistic children. However, research has yet to specifically examine the potential contributing role of sensory problems in predicting physical aggression.Self-injurious behavior also appears to be relevant to the occurrence of aggression. Individuals with autism are at an increased risk for demonstrating self-injurious behaviors, as compared to those without autism, with prevalence rates ranging from 30% to 53%. Although self-injury and other forms of challenging behaviors have been considered to be distinct forms of behavior, they are often related. For example, physical aggression and self-injury have been significantly associated among individuals with severe intellectual impairment and there is evidence that self-injurious behaviors are precursors of later aggression in this population. However, similar studies have not investigated the relationship between self-injury and physical aggression in autistic children.

Lastly, gastrointestinal (GI) problems may also have relevance to the occurrence of aggression. GI problems are common in autistic children, with prevalence rates ranging from 24% to 70% or higher, depending on symptom definitions. Although there some evidence of an association between behavior problems and GI problems, a population-based study of autistic children did not find significant differences in aggression when comparing children with and without GI problems.

Predictors

Although the nature and developmental course of aggression have been a focus of research with typically developing populations, there have been few large-scale studies of group-level predictors of aggression among individuals with autism. Consequently, it is unclear whether findings from the general population are applicable to autistic children and adolescents. In an effort to investigate the extent of the problem in children and adolescents with autism, a recent large-scale study published in Research in Autism Spectrum Disorders examined the prevalence and correlates of physical aggression in a sample of 1584 children and adolescents with ASD enrolled in the Autism Treatment Network (ATN), a multi-site network of 17 autism centers across the US and Canada. The results indicated that the prevalence of aggression was 53% across the entire sample of children, with highest prevalence among young children. These results are highly consistent with recently reported prevalence rates (56%) in another large-scale study of children and adolescents with autism. The results also indicate that age-related decreases in aggression in autistic children are similar to what has been observed in typically developing children. It should be noted, however, that a large percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate physical aggression. Thus, the relative decrease in aggression over time must be balanced by the finding that these behaviors continued to occur at a high rate among a large portion of adolescents with autism.

In terms of predictors, the results indicated that self-injury was highly associated with aggression among children with autism. This is consistent with the findings of other studies showing a strong association between self-injury and other challenging behaviors. The current results add to existing literature, and suggest that autistic children who demonstrate self-injury may be at risk for more severe behavioral problems.

Sleep problems emerged as a second significant predictor aggression. This association between sleep problems and aggression is largely consistent with previous findings among both typically developing children and those with autism, indicating may underlie (and exacerbate) aggressive behavior patterns for many autistic children. It should also be noted that sleep problems have been found to be associated with self-injurious behaviors among individuals with intellectual disabilities and that these two conditions may be related. In fact, there is some developing evidence suggesting shared neurobiological basis for both sleep disturbance and self-injurious behavior.

Sensory problems were also significantly associated with aggression. These findings are consistent with similar associations between sensory issues and aggression among typically developing children. While previous research has demonstrated an association between sensory problems and broadly defined behavior problems, the current results extend these previous findings by demonstrating a specific relationship between sensory problems and physical aggression.

Comparisons also indicated that children with aggression were more likely to experience GI problems, communication skill difficulties, and social skills difficulties. However, these variables did not appear as significant predictors of aggression, indicating that self-injury, sleep problems, and sensory issues accounted for the majority of the variance in predicting aggression.

In regards to potential sex differences, the results indicate that girls and boys with autism were equally likely to engage in aggression. This finding was unexpected in that research has consistently shown a significant gender difference among children without autism, with boys being much more likely to engage in physical aggression than girls. The results of the study suggest that the sex differential in aggression may not be salient in the autistic population.

Implications

This study provides evidence that challenging behavior may be much more prevalent among children with autism than in the general population and that some comorbid problems may place individuals at risk for aggression. Aggression was significantly associated with a number of clinical features, including self-injury, sleep problems, sensory problems, GI problems, and communication and social functioning. However, self-injury, sleep problems, and sensory problems were most strongly associated with aggression. These findings indicate that co-occurring problems specific to the autism phenotype may play an important role in the occurrence of aggression and that it is important to consider multiple domains of functioning when assessing and treating aggression in autistic children. For example, increased attention should be given to the identification and treatment of sleep problems, self-injury, and sensory problems. Given the significant relationship between sleep problems and aggression, it is possible that treatments targeting sleep problems may help reduce maladaptive behavior. Thus, assessment and treatment of sleeping problems might be included as a standard and integrated part of the assessment and treatment of autism. Programs for children with autism should also integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. Behavioral interventions, particularly those
based upon applied behavior analysis (ABA), have long had empirical support for
addressing problematic behavior (for a review, see Schreibman, 2000). A
comprehensive treatment plan for treating aggressive behaviors in children with
autism begins with a precise and thorough assessment, followed by implementation
of a comprehensive treatment plan.Although assessment tools are limited, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Co-occurring disorders should also be carefully investigated when severe or worsening symptoms are present that are not responding to traditional methods of intervention. It is important to take the time to analyze these underlying
causes of aggressive behavior in children with autism. By understanding the
triggers of aggression, we are able to choose the most effective
intervention strategies. Once we understand the function or goal of student behavior, we can begin to teach alternative replacement behavior and new interaction skills. Further research is needed in order to better understand the characteristics and course of different types of aggression. For example, future research should examine the longitudinal course of aggression, the role of these associated problems in predicting improvement or worsening of aggression, and possible changes in aggression in response to treatment for these co-occurring problems. Studies are also needed to examine the role of additional family- and community-level variables in the prediction and maintenance of aggression among children with autism.

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